Two years into the pandemic, researchers are still trying to understand what makes some people more likely than others to die from Covid-19. Although we know some of the risk factors — such as age and underlying diseases — others are less clear. Identifying them can ease our current pain, protect communities from future pandemics, and direct us toward some of the societal fractures that we must urgently try to repair.
One of the most surprising answers to this question is one that seems to have a relatively straightforward solution: Internet access.
In March of this year, researchers at the University of Chicago published a study in the journal JAMA Network is open which showed that one of the factors most consistently associated with a higher risk of death from Covid-19 in the United States is the lack of Internet access, whether broadband, dial-up or cellular. This was regardless of other demographic risk factors such as socioeconomic status, education, age, disability, rent burden, health insurance coverage, or immigration status.
The study authors estimated that for every additional 1 percent of county residents who had an Internet connection, between 2.4 and six deaths per 100,000 people. It can be prevented, depending on the composition of the area.
The results came with more surprises. The trend was true not only in rural areas with sparse internet access, but also in urban areas, where most homes can be connected to broadband. Internet. That is, people who can access the internet in cities but either don’t or can’t are also at greater risk of dying from Covid-19.
“We believe this finding indicates the need for more awareness,” the study authors wrote in the paper. “Populations with limited Internet access remain understudied and are often excluded in epidemiological research.”
Questions still remain. Why does internet access seem to be protective? And would increasing it lead to meaningful improvements in public health?
The answers to these questions matter because while the US market in general has treated internet access as a luxury, the Covid-19 pandemic has revealed that being able to get online may be a matter of life or death.
Explaining Internet inequality in America
Internet access has been inequitable for almost as long as the Internet has existed.
In 2000, when the Pew Research Center first began collecting data on Americans’ Internet use, its researchers found significant gaps: Older Americans, lower-income people, minorities, people with less education, and those living in rural areas were less likely to do so. Be online.
And while some of those gaps have since narrowed, most have stubbornly remained. More than a quarter of Americans still don’t have broadband internet at home, and the proportion who don’t have internet access is twice as high for those without any college education and those who earn less than $30,000 a year. Only 63 percent of rural homes have widespread access, as do about half of those who live on tribal lands—even if they have a computer.
These prejudices did not arise by chance. In the United States, private ISPs have developed broadband infrastructure Internet access where it was profitable. As a result, many of the country’s most marginalized communities have the fewest, most expensive, and lowest-quality options when it comes to their ISP.
As these access gaps persist over the years, more and more health services are becoming available online. That left those without access unable to use telemedicine, or even easily search for information about health conditions. Over the past few years, researchers have begun to see Internet access, particularly high-speed broadband, as an essential component of health – something vital to connecting people not only to health care, but also to food, housing, education and income, all of which are social determinants of health.
Then, when Covid-19 pushed routine visits to health care providers into the telehealth space, people without access to the Internet – many of whom are underserved – found it difficult to access health care. Home broadband drew an ever clearer line between the haves and the have-nots; Internet bandwidth access abruptly limit access to educational instructions, economic stability, food pantry subscriptions, vaccine availability and safety information, human contact, and many other resources.
Before the pandemic, broadband Internet access has only sometimes been described as a social determinant of health, but over the past two years its centrality has crystallized. said Natalie Benda, a healthcare informatics researcher who co-authored an editorial on the topic in american journal of public health.
The presence of broadband Internet access means access to education and financial stability, which contributes to our well-being. Binda said communications are so powerful that the FCC is now framing broadband Internet access as a “super” determinant of health.
There is a huge amount of monitoring data showing broadband Internet access tracks other factors that predict health, such as income, ethnicity, and education. However, there is almost no empirical data linking internet access to the same health outcomes.
The pandemic has provided an opportunity to accelerate our understanding of how Internet access is linked to health because it has exacerbated many of the existing inequalities that underlie health inequalities.
Linking internet access to Covid-19 deaths
Chinyun Lin, one of the study’s co-authors, said that before the pandemic, researchers may not have considered including Internet access as a variable. However, another study has linked home broadband internet to Covid-19 deaths in the Chicago area. This finding, combined with the team’s epidemiological experiences of returning to life online, led them to consider internet access as essential in the context of Covid-19. The authors relied on census data for households that did not have access to any form of the Internet, whether broadband, dial-up, satellite, or cellular. (Note: The study does not directly compare the effect of broadband versus dial-up or any other category.)
In Lynn’s study, Internet access was the only factor associated with higher mortality rates in rural, urban, and suburban areas (the study also included measures of socioeconomic status, education, age, and other demographic risk factors). The effect was strong: In rural areas, a 1 percent decrease in county internet access was associated with 2.4 deaths per 100,000 people. But the effect was stronger in urban areas, where the same difference in access was associated with about six deaths per 100,000 people.
Study coordinator and co-author, Susan Paikin, said investigators were not surprised to discover that low internet access was associated with higher death rates. But they were surprised by how strong the bond was, and were surprised to find it existed in both rural and urban areas.
None of the other demographic variables the team examined — including socioeconomic status — were significant in all three types of communities, Paikin said. There is a lot of interest and research in broadband gaps in rural areas, she said, “but I think this is missing a lot of what is clearly happening in urban and suburban communities.” This means that the lack of Internet access is not just a rural infrastructure problem. It is also likely to be an affordability issue in cities.
Questions remain about why from all of that
Internet access doesn’t boost your immune system or filter the air – so what mechanism explains the strong link between lower digital connectivity and higher death rates from Covid-19?
Lack of internet access in the family could point to a variety of other factors that are known to increase the risk of death from Covid-19: old age, housing problems, or difficulty accessing quality health care. But Lin’s study took these characteristics into account in the analysis, suggesting that a lack of internet access was the real source of the risks.
Lynn assumes it’s all about a lack of information. “If they have limited access to the internet, they rely more on their personal network or their local network for information related to Covid-19,” she said. This could lead to being influenced by low-quality information that raises mistrust of vaccines, for example. But her study was not designed to show why Covid-19 deaths are so common in counties where Internet access has been more scarce, she says, and more research is needed to answer that question.
New funding for broadband expansion will solve some access issues but not their root cause
The good news here is that Internet access is a problem that the US government has allocated funds to solve.
In November, Congress passed an infrastructure bill that included $65 billion to fund broadband Internet expansion. Two-thirds of the funding will support infrastructure construction, largely in rural areas of each state, and a large portion will pay an additional $30 to support low-income households for Internet access.
Small amounts are earmarked for programs to teach new users the technical skills they need to use the Internet, programs to expand access in tribal communities, and other initiatives.
This means that a lot of the new money is “going toward rural areas without access to what we consider basic broadband today,” said Ry Marcattilio-McCracken, a senior researcher with the Community Self-Reliance Institute’s Community Broadband Networking Initiative.
In many ways, this is a good thing: since rural communities were not profitable areas of development for the telecommunications monopolies they serve, the infrastructure to support rural access to lower-speed broadband Internet has been woefully underdeveloped.
Marcatelio McCracken said the bill does little to address disparities in areas that have good infrastructure but are low-cost. Residents of many cities can’t afford to pay a monthly $80 bill for broadband internet, even with the $30 subsidies the new funding will provide. And because the bill discourages competition, urban residents won’t have new ISPs to choose from anytime soon.
One promising solution to urban internet insecurity — one that the Biden administration initially wrote into the bill — is to create collaborative community networks. Municipal ISPs are able to provide faster download speeds, lower rates, and better service to city residents — plus, they’re relatively uncomplicated to set up, and easy to sign up for, say, city-operated electrical utilities, Marcattilio-McCracken said.
He said they need startup funding, but at the end of the day, these providers are prioritizing access over profit. “They have a completely different set of motivations in building a functioning infrastructure, and that means building more resilient communities,” said Marcattilio-McCracken.
“Broadband Internet access should be a public good,” Benda said, especially given the research linking access to health. It is a need, not a privilege. That means making it as accessible and adjustable as using water or electricity, she says.
Will expanding access improve health? It is an experience worth experiencing.
Researchers know that lack of internet access is associated with poor health outcomes, but one thing remains to be seen: Does expanding access work as an intervention to improve health?
In the coming years, broadband expansion will at least provide a natural experiment to test this question. Regardless, the pandemic has shown that increased access is essential for many reasons.
Improving internet access now will have positive effects that will last well beyond the pandemic, Paikin said. Telehealth and online learning for children and adults are likely to remain. “This will certainly not be our last pandemic,” she said, “nor our last public health emergency.” Whatever challenges may come, increase broadband Internet access seems to help people through them.